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Chauhan K, Tyagi M. Update on non-infectious uveitis treatment: anti-TNF-alpha and beyond. FRONTIERS IN OPHTHALMOLOGY 2024; 4:1412930. [PMID: 39157460 PMCID: PMC11327136 DOI: 10.3389/fopht.2024.1412930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/16/2024] [Indexed: 08/20/2024]
Abstract
Non-infectious uveitis (NIU) encompasses a range of conditions marked by inflammation within various layers of the eye. NIU is a significant contributor to irreversible vision loss among the working-age population in developed countries. The aim of treating uveitis is to manage inflammation, prevent its recurrences and to restore or salvage vision. Presently, the standard treatment protocol for NIU involves initiating corticosteroids as the primary therapeutic agents, although more aggressive approaches and steroid sparing agent may be necessary in certain cases. These advanced treatments option include synthetic immunosuppressants like antimetabolites, calcineurin inhibitors and alkylating agents. For patients who exhibit an intolerance or resistance to corticosteroids and conventional immunosuppressive therapies, biologic agents have emerged as a promising alternative. Notably, among the biologic treatments evaluated, TNF-α inhibitors, anti-CD20 therapy and alkylating agents have shown considerable efficacy. In this review, we delve into the latest evidence surrounding the effectiveness of biologic therapy and introduce novel therapeutic strategies targeting immune components as potential avenues for advancing treatment of NIU.
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Affiliation(s)
- Khushboo Chauhan
- Saroja A Rao Centre for Uveitis, L V Prasad Eye Institute, Hyderabad, India
- Smt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L V Prasad Eye Institute, Hyderabad, India
| | - Mudit Tyagi
- Saroja A Rao Centre for Uveitis, L V Prasad Eye Institute, Hyderabad, India
- Smt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L V Prasad Eye Institute, Hyderabad, India
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Stübiger N, Ruprecht K, Pleyer U. [Uveitis and multiple sclerosis : Clinical aspects, diagnostics, management and treatment]. DIE OPHTHALMOLOGIE 2024; 121:665-678. [PMID: 39037464 DOI: 10.1007/s00347-024-02084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/23/2024]
Abstract
Approximately 0.5-1% of patients with multiple sclerosis (MS) have co-existing uveitis. Both intraocular inflammation and MS mainly affect women in younger adulthood. The MS in patients is most frequently associated with an often bilateral intermediate uveitis with typical concomitant retinal vasculitis. Both diseases share similar characteristics with chronic inflammatory diseases with a relapsing course and an immune-mediated pathogenesis; however, it is still unclear whether the co-occurrence of uveitis and MS in the same patient represents a coincidence of two separate disease entities or whether uveitis is a rare clinical manifestation of MS. In the differential diagnostics of intermediate uveitis, clinical symptoms and signs of MS should be considered. As both diseases are considered to be immune-mediated, immunotherapy is the main treatment option. In recent years the range of medications has expanded and includes several disease modifying drugs (biologics). When selecting the active substance it must be taken into account that tumor necrosis factor (TNF) alpha blockers are contraindicated in patients with MS.
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Affiliation(s)
- Nicole Stübiger
- Klinik und Poliklinik für Augenheilkunde, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Klemens Ruprecht
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Uwe Pleyer
- Universitäts-Augenklinik, Charité, Campus Virchow Klinikum - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Deutschland.
- Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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Guan Y, Li F, Li N, Yang P. Decoding Behcet's Uveitis: an In-depth review of pathogenesis and therapeutic advances. J Neuroinflammation 2024; 21:133. [PMID: 38778397 PMCID: PMC11112928 DOI: 10.1186/s12974-024-03123-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/04/2024] [Indexed: 05/25/2024] Open
Abstract
Behcet's disease (BD) is a rare but globally distributed vasculitis that primarily affects populations in the Mediterranean and Asian regions. Behcet's uveitis (BU) is a common manifestation of BD, occurring in over two-thirds of the patients. BU is characterized by bilateral, chronic, recurrent, non-granulomatous uveitis in association with complications such as retinal ischemia and atrophy, optic atrophy, macular ischemia, macular edema, and further neovascular complications (vitreous hemorrhage, neovascular glaucoma). Although the etiology and pathogenesis of BU remain unclear, numerous studies reveal that genetic factors (such as HLA-B51), dysregulated immune responses of both the innate and adaptive immune systems, infections (such as streptococcus), and environmental factors (such as GDP) are all involved in its development. Innate immunity, including hyperactivity of neutrophils and γδT cells and elevated NK1/NK2 ratios, has been shown to play an essential role in this disease. Adaptive immune system disturbance, including homeostatic perturbations, Th1, Th17 overaction, and Treg cell dysfunction, is thought to be involved in BU pathogenesis. Treatment of BU requires a tailored approach based on the location, severity of inflammation, and systemic manifestations. The therapy aims to achieve rapid inflammation suppression, preservation of vision, and prevention of recurrence. Systemic corticosteroids combined with other immunosuppressive agents have been widely used to treat BU, and beneficial effects are observed in most patients. Recently, biologics have been shown to be effective in treating refractory BU cases. Novel therapeutic targets for treating BU include the LCK gene, Th17/Treg balance, JAK pathway inhibition, and cytokines such as IL-17 and RORγt. This article summarizes the recent studies on BU, especially in terms of pathogenesis, diagnostic criteria and classification, auxiliary examination, and treatment options. A better understanding of the significance of microbiome composition, genetic basis, and persistent immune mechanisms, as well as advancements in identifying new biomarkers and implementing objective quantitative detection of BU, may greatly contribute to improving the adequate management of BU patients.
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Affiliation(s)
- Yuxuan Guan
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China
- The Academy of Medical Sciences, Zhengzhou University, Zhengzhou, 450052, People's Republic of China
| | - Fuzhen Li
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China
| | - Na Li
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China
| | - Peizeng Yang
- Department of Ophthalmology, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Zhengzhou, 450052, People's Republic of China.
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Stascheit F, Rübsam A, Otto C, Meisel A, Ruprecht K, Pleyer U. Anti-CD20 therapy for multiple sclerosis associated uveitis: a case series. Eur J Neurol 2022; 29:3028-3038. [PMID: 35716269 DOI: 10.1111/ene.15453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND About 1% of patients with multiple sclerosis (MS) suffer from uveitis, but data on the effects of immunotherapies for MS on MS-associated uveitis are scarce. OBJECTIVE To investigate the ophthalmological outcomes in patients with MS-associated uveitis treated with anti-CD20 therapy. METHODS Retrospective study of 12 eyes of 6 patients with MS-associated uveitis, refractory to previous immunotherapies. Uveitis activity was assessed before initiation of anti-CD20 therapy and at regular follow-up visits. Primary outcome measures were vitreous haze score, retinal vasculitis score determined on fluorescein angiography images, macular edema as quantified by central retinal thickness (CRT) on optical coherence tomography, and visual acuity. Secondary outcomes included the number of annualized uveitis or MS relapses, disease activity on cerebral magnetic resonance imaging (cMRI) and the expanded disability status scale (EDSS). RESULTS After a median (IQR) treatment time of 28.5 (8-43) months, anti-CD20 therapy was associated with an improvement of vitreous haze score (p=0.002), retinal vasculitis score (p=0.001), CRT (p=0.002), and visual acuity (p=0.007). The median (IQR) annualized uveitis relapse rate declined from 0.59 (0.56-0.94) before to 0 (0-0.49) after the start of anti-CD20 therapy. The median (IQR) annualized MS relapse rate declined from 0.62 (0.26-2.84) before to 0 (0-0) after the start of anti-CD20 therapy. After initiation of anti-CD20 therapy, there was no disease activity on cMRI and the EDSS improved (n=2) or remained stable (n=4). No severe adverse events were observed. CONCLUSION These findings suggest that anti-CD20 therapy may be a valuable treatment option for MS-associated uveitis.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anne Rübsam
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carolin Otto
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Uwe Pleyer
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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An update on long-acting therapies in chronic sight-threatening eye diseases of the posterior segment: AMD, DMO, RVO, uveitis and glaucoma. Eye (Lond) 2022; 36:1154-1167. [PMID: 34974541 PMCID: PMC9151779 DOI: 10.1038/s41433-021-01766-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/19/2021] [Accepted: 09/07/2021] [Indexed: 12/26/2022] Open
Abstract
In the real-world setting, there is suboptimal compliance with treatments that require frequent administration and assessment visits. This undertreatment frequently has negative consequences in eye disease and carries a real risk to vision. For example, patients with glaucoma risk progression of visual loss even with a small number of missed doses, and patients with neovascular age-related degeneration (nAMD) who fail to attend a bi-monthly clinic appointment to receive an intravitreal anti-vascular endothelial growth factor (VEGF) drug injections may lose the initial vision gains in vision. Protracted regular treatment schedules represent a high burden not only for patients and families, but also healthcare professionals, systems, and ultimately society too. There has been a clear need for longer-acting therapies that reduce the frequency, and therefore the burden, of treatment interventions. Several longer-acting interventions for nAMD, diabetic macular oedema, retinal vein occlusion, uveitis and glaucoma have either been developed or are in late-phase development, some of which employ novel mechanisms of actions, and all of which of promise longer (≥3 month) treatment intervals. This review delivers an overview of anti-VEGF agents with longer durations of action, DARPins, bispecific anti-VEGF/Ang2 therapies, anti-PDGF and anti-integrin therapy, Rho-kinase inhibitors, the Port Delivery System, steroids, gene therapy for retina and uveitis, and for glaucoma, ROCK inhibitors, implants and plugs, and SLT laser and MIGS. The review also refers to the potential of artificial intelligence to tailor treatment efficacy with a resulting reduction in treatment burden.
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A Comprehensive Update on Retinal Vasculitis: Etiologies, Manifestations and Treatments. J Clin Med 2022; 11:jcm11092525. [PMID: 35566655 PMCID: PMC9101900 DOI: 10.3390/jcm11092525] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 12/18/2022] Open
Abstract
Retinal vasculitis is characterized by inflammatory involvement of retinal arterioles, venules and/or capillaries and can be associated with a myriad of systemic and ophthalmic diseases. In this review, we have comprehensively discussed the etiologies, clinical manifestations, and presentations of retinal vasculitis. We have also included newer advances in imaging in retinal vasculitis such as OCTA and widefield imaging.
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Gupta S, Shyamsundar K, Agrawal M, Vichare N, Biswas J. Current Knowledge of Biologics in Treatment of Noninfectious Uveitis. J Ocul Pharmacol Ther 2022; 38:203-222. [DOI: 10.1089/jop.2021.0098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Simple Gupta
- Department of Ophthalmology, Command Hospital, Pune, India
| | - K. Shyamsundar
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Mohini Agrawal
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Nitin Vichare
- Department of Ophthalmology, Command Hospital, Pune, India
| | - Jyotirmay Biswas
- Department of Uveitis and Ocular Pathology, Sankara Netralaya, Chennai, India
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Touhami S, Gueudry J, Leclercq M, Touitou V, Ghembaza A, Errera MH, Saadoun D, Bodaghi B. Perspectives for immunotherapy in noninfectious immune mediated uveitis. Expert Rev Clin Immunol 2021; 17:977-989. [PMID: 34264142 DOI: 10.1080/1744666x.2021.1956313] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: Noninfectious uveitis (NIU) is one of the leading causes of blindness worldwide. In adult patients, anterior NIU is usually managed with topical corticosteroids. In intermediate, posterior uveitis. and panuveitis, systemic corticosteroids are used especially in case of bilaterality or association with systemic disease. Biotherapies are recommended in case of inefficacy or intolerance to corticosteroids or conventional immunosuppressive drugs. Anti-TNF-α agents are by far the most widely used biotherapies. In case of failure or poor tolerance to anti-TNF-α, new targeted therapies can be proposed.Areas covered: We present and discuss an updated overview on biologics and biotherapies in NIU.Expert opinion: In case of dependency to systemic or intravitreal steroids, sight-threatening disease, and/or failure of conventional immunosuppressive drugs, anti-TNF-α are used as first-line biologics to achieve quiescence of inflammation. Anti-interleukin-6 is another option that may be proposed as first-line biologic or in case of poor efficacy of anti-TNF-α. Interferon can be directly proposed in specific indications (e.g. refractory macular edema, sight-threatening Behçet's uveitis). In the rare cases that remain unresponsive to traditional biotherapies, novel molecules, such as Janus-associated-kinase and anti-phosphodiesterase-4-inhibitors can be used. Therapeutic response must always be evaluated by clinical and appropriate ancillary investigations.
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Affiliation(s)
- Sara Touhami
- Department of Ophthalmology, DHU ViewRestore, Sorbonne Université, Paris, France
| | - Julie Gueudry
- Department of Ophthalmology Charles Nicolle University Hospital, Rouen, France
| | - Mathilde Leclercq
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département De Médecine Interne Et Immunologie Clinique, Paris, France, Centre National De Références Maladies Autoimmunes Systémiques Rares, Centre National De Références Maladies Autoinflammatoires Et Amylose Inflammatoire; Inflammation-Immunopathology-Biotherapy Department (DMU 3iD); INSERM 959, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France.,CHU Rouen, Department of Internal Medicine, Rouen, France
| | - Valérie Touitou
- Department of Ophthalmology, DHU ViewRestore, Sorbonne Université, Paris, France
| | - Amine Ghembaza
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département De Médecine Interne Et Immunologie Clinique, Paris, France, Centre National De Références Maladies Autoimmunes Systémiques Rares, Centre National De Références Maladies Autoinflammatoires Et Amylose Inflammatoire; Inflammation-Immunopathology-Biotherapy Department (DMU 3iD); INSERM 959, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Marie Hélène Errera
- Ophthalmology Department and Laboratory and DHU Sight Restore, Centre Hospitalier National d'Ophtalmologie Des Quinze-Vingts, Sorbonne Université, Paris, France.,Department of Ophthalmology, Pittsburgh University Hospital, Pittsburgh, PA, USA
| | - David Saadoun
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département De Médecine Interne Et Immunologie Clinique, Paris, France, Centre National De Références Maladies Autoimmunes Systémiques Rares, Centre National De Références Maladies Autoinflammatoires Et Amylose Inflammatoire; Inflammation-Immunopathology-Biotherapy Department (DMU 3iD); INSERM 959, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, DHU ViewRestore, Sorbonne Université, Paris, France
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Agrawal H, Doan H, Pham B, Khosla A, Babu M, McCluskey P, Nguyen QD, Sangwan V, Reddy S, Sawhney S, Tyagi M. Systemic immunosuppressive therapies for uveitis in developing countries. Indian J Ophthalmol 2020; 68:1852-1862. [PMID: 32823402 PMCID: PMC7690522 DOI: 10.4103/ijo.ijo_1548_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
There are multiple approaches to inhibit inflammatory molecules and pathways in noninfectious uveitis. The cornerstone of local and systemic anti-inflammatory treatment is corticosteroid therapy. Corticosteroids remain the most potent and efficacious drugs for treating intraocular inflammation. However, their long-term use is limited by their medium- and long-term side effects, which are a major concern. The approach taken to limit corticosteroid side effects is to introduce steroid-sparing agents that suppress the inflammatory pathways and immune response differently than corticosteroids. There are several classes of such drugs that are affordable, effective, and generally well-tolerated. Relatively recently, an increasing range of biologic agents has become available to treat intraocular inflammation. However, the relatively expensive cost of these therapies limits their use in the developing world. This systemic review aimst to discuss the use of corticosteroids and different immunosuppressive regimens in the management of various uveitides.
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Affiliation(s)
| | - Hien Doan
- Byers Eye Institute, Palo Alto, CA, USA
| | | | | | | | | | | | | | | | | | - Mudit Tyagi
- L V Prasad Eye Institute, Hyderabad, Telangana, India
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